Updates in Surgery

, Volume 68, Issue 3, pp 295–305 | Cite as

Indications, technique, and results of robotic pancreatoduodenectomy

  • Niccolò Napoli
  • Emanuele F. Kauffmann
  • Francesca Menonna
  • Vittorio Grazio Perrone
  • Stefania Brozzetti
  • Ugo BoggiEmail author
Original Article
Part of the following topical collections:
  1. Pancreatic Surgery


Robotic assistance improves surgical dexterity in minimally invasive operations, especially when fine dissection and multiple sutures are required. As such, robotic assistance could be rewarding in the setting of robotic pancreatoduodenectomy (RPD). RPD was implemented at a high volume center with preemptive experience in advanced laparoscopy. Indications, surgical technique, and results of RPD are discussed against the background of current literature. RPD was performed in 112 consecutive patients. Conversion to open surgery was required in three patients, despite nine required segmental resection and reconstruction of the superior mesenteric/portal vein. No patient was converted to laparoscopy. A pancreato-jejunostomy was created in 106 patients (94.6 %), using either a duct-to-mucosa (n = 82; 73.2 %) or an invaginating (n = 24; 21.4 %) technique. Pancreato-gastrostomy was performed in one patient, the pancreatic duct was occluded in two patients, and a pancreatico-cutaneous fistula was created in three patients. Mean operative time was 526.3 ± 102.4 in the entire cohort and reduced significantly over the course of time. Experience was also associated with reduced rates of delayed gastric emptying and increased proportion of malignant tumor histology. Ninety day mortality was 3.6 %. Postoperative complications occurred in 83 patients (74.1 %) with a median comprehensive complication index of 20.9 (0–30.8). Clinically relevant pancreatic fistula occurred in 19.6 % of the patients. No grade C pancreatic fistula was noted in the last 72 consecutive patients. RPD is safely feasible in selected patients. Implementation of RPD requires sound experience with open pancreatoduodenectomy and advanced laparoscopic procedures, as well as specific training with the robotic platform.


Robot da Vinci Pancreatoduodenectomy Pancreatectomy Laparoscopy 


Compliance with ethical standards

Conflict of interest

The authors do not have any conflict of interest to disclose.

Ethical approval

All procedures analyzed in this study were conducted in accordance with the ethical standards of our Institution, and with the 1964 Helsinki declaration and its later amendments.

Informed consent

All participanting individuals provided informed consent.


  1. 1.
    Giulianotti PC, Coratti A, Angelini M, Sbrana F, Cecconi S, Balestracci T, Caravaglios G (2003) Robotics in general surgery: personal experience in a large community hospital. Arch Surg 138:777–784. doi: 10.1001/archsurg.138.7.777 CrossRefPubMedGoogle Scholar
  2. 2.
    Boggi U, Amorese G, Vistoli F, Caniglia F, De Lio N, Perrone V, Barbarello L, Belluomini M, Signori S, Mosca F (2015) Laparoscopic pancreaticoduodenectomy: a systematic literature review. Surg Endosc 29:9–23. doi: 10.1007/s00464-014-3670-z CrossRefPubMedGoogle Scholar
  3. 3.
    Gagner M, Pomp A (1994) Laparoscopic pylorus-preserving pancreatoduodenectomy. Surg Endosc 8:408–410CrossRefPubMedGoogle Scholar
  4. 4.
    De Rooij T, Besselink MG, Shamali A, Butturini G, Busch OR, Edwin B, Troisi R, Fernández-Cruz L, Dagher I, Bassi C, Abu Hilal M, DIPLOMA trial group (2016) Pan-European survey on the implementation of minimally invasive pancreatic surgery with emphasis on cancer. HPB (Oxford) 18:170–176. doi: 10.1016/j.hpb.2015.08.005 CrossRefGoogle Scholar
  5. 5.
    Speicher PJ, Nussbaum DP, White RR, Zani S, Mosca PJ, Blazer DG 3rd, Clary BM, Pappas TN, Tyler DS, Perez A (2014) Defining the learning curve for team-based laparoscopic pancreaticoduodenectomy. Ann Surg Oncol 21:4014–4019. doi: 10.1245/s10434-014-3839-7 CrossRefPubMedGoogle Scholar
  6. 6.
    Boggi U, Vistoli F, Signori S, D’Imporzano S, Amorese G, Consani G, Guarracino F, Melfi F, Mussi A, Mosca F (2011) Robotic renal transplantation: first European case. Transpl Int 24:213–218. doi: 10.1111/j.1432-2277.2010.01191.x CrossRefPubMedGoogle Scholar
  7. 7.
    Boggi U, Signori S, Vistoli F, D’Imporzano S, Amorese G, Consani G, Guarracino F, Marchetti P, Focosi D, Mosca F (2012) Laparoscopic robot-assisted pancreas transplantation: first world experience. Transplantation 93:201–206. doi: 10.1097/TP.0b013e318238daec CrossRefPubMedGoogle Scholar
  8. 8.
    Boggi U, Moretto C, Vistoli F, D’Imporzano S, Mosca F (2009) Robotic suture of a large caval injury caused by endo-GIA stapler malfunction during laparoscopic wedge resection of liver segments VII and VIII en-bloc with the right hepatic vein. Minim Invasive Ther Allied Technol 18:306–310. doi: 10.1080/13645700903201001 CrossRefPubMedGoogle Scholar
  9. 9.
    Pietrabissa A, Boggi U, Vistoli F, Moretto C, Ghilli M, Mosca F (2004) Laparoscopic living donor nephrectomy in Italy: a national profile. Transplant Proc 36:460–463CrossRefPubMedGoogle Scholar
  10. 10.
    Pietrabissa A, Moretto C, Carobbi A, Boggi U, Ghilli M, Mosca F (2002) Hand-assisted laparoscopic low anterior resection: initial experience with a new procedure. Surg Endosc 16:431–435CrossRefPubMedGoogle Scholar
  11. 11.
    Pietrabissa A, Moretto C, Boggi U, Di Candio G, Mosca F (2004) Laparoscopic distal pancreatomy: are we ready for a standardized technique? Semin Laparosc Surg 11:179–183PubMedGoogle Scholar
  12. 12.
    Boggi U, Napoli N, Costa F, Kauffmann EF, Menonna F, Iacopi S, Vistoli F, Amorese G (2016) Robotic-assisted pancreatic resections. World J Surg 1–11. doi: 10.1007/s00268-016-3565-3 PubMedGoogle Scholar
  13. 13.
    Boggi U, Signori S, De Lio N, Perrone VG, Vistoli F, Belluomini M, Cappelli C, Amorese G, Mosca F (2013) Feasibility of robotic pancreaticoduodenectomy. Br J Surg 100:917–925. doi: 10.1002/bjs.9135 CrossRefPubMedGoogle Scholar
  14. 14.
    Boggi U, Del Chiaro M, Croce C et al (2009) Prognostic implications of tumor invasion or adhesion to peripancreatic vessels in resected pancreatic cancer. Surgery 146:869–881. doi: 10.1016/j.surg.2009.04.029 CrossRefPubMedGoogle Scholar
  15. 15.
    Bassi C, Dervenis C, Butturini G, Fingerhut A, Yeo C, Izbicki J, Neoptolemos J, Sarr M, Traverso W, Buchler M, International Study Group on Pancreatic Fistula Definition (2005) Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery 138:8–13. doi: 10.1016/j.surg.2005.05.001 CrossRefPubMedGoogle Scholar
  16. 16.
    Wente MN, Bassi C, Dervenis C, Fingerhut A, Gouma DJ, Izbicki JR, Neoptolemos JP, Padbury RT, Sarr MG, Traverso LW, Yeo CJ, Büchler MW (2007) Delayed gastric emptying (DGE) after pancreatic surgery: a suggested definition by the International Study Group of Pancreatic Surgery (ISGPS). Surgery 142:761–768. doi: 10.1016/j.surg.2007.05.005 CrossRefPubMedGoogle Scholar
  17. 17.
    Wente MN, Veit JA, Bassi C, Dervenis C, Fingerhut A, Gouma DJ, Izbicki JR, Neoptolemos JP, Padbury RT, Sarr MG, Yeo CJ, Büchler MW (2007) Postpancreatectomy hemorrhage (PPH): an International Study Group of Pancreatic Surgery (ISGPS) definition. Surgery 142:20–25. doi: 10.1016/j.surg.2007.02.001 CrossRefPubMedGoogle Scholar
  18. 18.
    Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240:205–213. doi: 10.1097/ CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Slankamenac K, Graf R, Barkun J, Puhan MA, Clavien PA (2013) The comprehensive complication index: a novel continuous scale to measure surgical morbidity. Ann Surg 258:1–7. doi: 10.1097/SLA.0b013e318296c732 CrossRefPubMedGoogle Scholar
  20. 20.
    van Heek NT, Kuhlmann KF, Scholten RJ, de Castro SM, Busch OR, van Gulik TM, Obertop H, Gouma DJ (2005) Hospital volume and mortality after pancreatic resection: a systematic review and an evaluation of intervention in the Netherlands. Ann Surg 242:781–788. doi: 10.1097/01.sla.0000188462.00249.36 CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Waterhouse MA, Burmeister EA, O’Connell DL, Ballard EL, Jordan SJ, Merrett ND, Goldstein D, Wyld D, Janda M, Beesley VL, Payne ME, Gooden HM, Neale RE (2016) Determinants of outcomes following resection for pancreatic cancer-a population-based study. J Gastrointest Surg 20:1471–1481. doi: 10.1007/s11605-016-3157-4 CrossRefPubMedGoogle Scholar
  22. 22.
    Napoli N, Kauffmann EF, Palmeri M, Miccoli M, Costa F, Vistoli F, Amorese G, Boggi U (2016) The learning curve in robotic pancreaticoduodenectomy. Dig Surg 33:299–307. doi: 10.1159/000445015 CrossRefPubMedGoogle Scholar
  23. 23.
    Boone BA, Zenati M, Hogg ME, Steve J, Moser AJ, Bartlett DL, Zeh HJ, Zureikat AH (2015) Assessment of quality outcomes for robotic pancreaticoduodenectomy: identification of the learning curve. JAMA Surg 150:416–422. doi: 10.1001/jamasurg.2015.17 CrossRefPubMedGoogle Scholar
  24. 24.
    Balzano G, Capretti G, Callea G, Cantù E, Carle F, Pezzilli R (2016) Overuse of surgery in patients with pancreatic cancer. A nationwide analysis in Italy. HPB (Oxford) 18:470–478. doi: 10.1016/j.hpb.2015.11.005 CrossRefGoogle Scholar
  25. 25.
    Szold A, Bergamaschi R, Broeders I, Dankelman J, Forgione A, Langø T, Melzer A, Mintz Y, Morales-Conde S, Rhodes M, Satava R, Tang CN, Vilallonga R, European Association of Endoscopic Surgeons (2015) European association of endoscopic surgeons (EAES) consensus statement on the use of robotics in general surgery. Surg Endosc 29:253–288. doi: 10.1007/s00464-014-3916-9 CrossRefPubMedGoogle Scholar
  26. 26.
    Sutton JM, Kooby DA, Wilson GC, Squires MH 3rd, Hanseman DJ, Maithel SK, Bentrem DJ, Weber SM, Cho CS, Winslow ER, Scoggins CR, Martin RC 2nd, Kim HJ, Baker JJ, Merchant NB, Parikh AA, Abbott DE, Edwards MJ, Ahmad SA (2014) Perioperative blood transfusion is associated with decreased survival in patients undergoing pancreaticoduodenectomy for pancreatic adenocarcinoma: a multi-institutional study. J Gastrointest Surg 18:1575–1587. doi: 10.1007/s11605-014-2567-4 CrossRefPubMedGoogle Scholar
  27. 27.
    Wellner UF, Kulemann B, Lapshyn H, Hoeppner J, Sick O, Makowiec F, Bausch D, Hopt UT, Keck T (2014) Postpancreatectomy hemorrhage-incidence, treatment, and risk factors in over 1000 pancreatic resections. J Gastrointest Surg 18:464–475. doi: 10.1007/s11605-013-2437-5 CrossRefPubMedGoogle Scholar
  28. 28.
    Feldman LS, Lee L, Fiore J (2015) What outcomes are important in the assessment of enhanced recovery after surgery (ERAS) pathways? Can J Anesth 62:120–130. doi: 10.1007/s12630-014-0263-1 CrossRefPubMedGoogle Scholar
  29. 29.
    Neville A, Lee L, Antonescu I et al (2014) Systematic review of outcomes used to evaluate enhanced recovery after surgery. Br J Surg 101:159–170. doi: 10.1002/bjs.9324 CrossRefPubMedGoogle Scholar
  30. 30.
    Bowyer AJ, Royse CF (2016) Postoperative recovery and outcomes—what are we measuring and for whom? Anaesthesia 71:72–77. doi: 10.1111/anae.13312 CrossRefPubMedGoogle Scholar
  31. 31.
    Heerkens HD, Tseng DS, Lips IM, van Santvoort HC, Vriens MR, Hagendoorn J, Meijer GJ, Borel Rinkes IH, van Vulpen M, Molenaar IQ (2016) Health-related quality of life after pancreatic resection for malignancy. Br J Surg 103:257–266. doi: 10.1002/bjs.10032 CrossRefPubMedGoogle Scholar
  32. 32.
    Giulianotti PC, Sbrana F, Bianco FM, Elli EF, Shah G, Addeo P, Caravaglios G, Coratti A (2010) Robot-assisted laparoscopic pancreatic surgery: single-surgeon experience. Surg Endosc 24:1646–1657. doi: 10.1007/s00464-009-0825-4 CrossRefPubMedGoogle Scholar
  33. 33.
    Morgan KA, Lancaster WP, Walters ML, Owczarski SM, Clark CA, McSwain JR, Adams DB (2016) Enhanced recovery after surgery protocols are valuable in pancreas surgery patients. J Am Coll Surg 222:658–664. doi: 10.1016/j.jamcollsurg.2015.12.036 CrossRefPubMedGoogle Scholar
  34. 34.
    Mosca F, Giulianotti PC, Balestracci T, Boggi U, Giardino D, Di Candio G, Rossi G, Fornaciari G (1994) Preservation of the pylorus in duodenocephalopancreatectomy in pancreatic and periampullary carcinoma. Chir Ital 46:59–67PubMedGoogle Scholar
  35. 35.
    Hüttner FJ, Fitzmaurice C, Schwarzer G, Seiler CM, Antes G, Büchler MW, Diener MK (2016) Pylorus-preserving pancreaticoduodenectomy (pp Whipple) versus pancreaticoduodenectomy (classic Whipple) for surgical treatment of periampullary and pancreatic carcinoma. Cochrane Database Syst Rev. doi: 10.1002/14651858.CD006053.pub6 Google Scholar
  36. 36.
    Su AP, Cao SS, Zhang Y, Zhang ZD, Hu WM, Tian BL (2012) Does antecolic reconstruction for duodenojejunostomy improve delayed gastric emptying after pylorus-preserving pancreaticoduodenectomy? A systematic review and meta- analysis. World J Gastroenterol 18:6315–6323. doi: 10.3748/wjg.v18.i43.6315 CrossRefPubMedPubMedCentralGoogle Scholar
  37. 37.
    Ding X, Zhu J, Zhu M, Li C, Jian W, Jiang J, Wang Z, Hu S, Jiang X (2011) Therapeutic management of hemorrhage from visceral artery pseudoaneurysms after pancreatic surgery. J Gastrointest Surg 15:1417–1425. doi: 10.1007/s11605-011-1561-3 CrossRefPubMedGoogle Scholar
  38. 38.
    Zureikat AH, Moser AJ, Boone BA, Bartlett DL, Zenati M, Zeh HJ 3rd (2013) 250 robotic pancreatic resections: safety and feasibility. Ann Surg 258:554–559. doi: 10.1097/SLA.0b013e3182a4e87c PubMedPubMedCentralGoogle Scholar
  39. 39.
    Balzano G, Maffi P, Nano R, Zerbi A, Venturini M, Melzi R, Mercalli A, Magistretti P, Scavini M, Castoldi R, Carvello M, Braga M, Del Maschio A, Secchi A, Staudacher C, Piemonti L (2013) Extending indications for islet autotransplantation in pancreatic surgery. Ann Surg 258:210–218. doi: 10.1097/SLA.0b013e31829c790d CrossRefPubMedGoogle Scholar

Copyright information

© Italian Society of Surgery (SIC) 2016

Authors and Affiliations

  • Niccolò Napoli
    • 1
  • Emanuele F. Kauffmann
    • 1
  • Francesca Menonna
    • 1
  • Vittorio Grazio Perrone
    • 1
  • Stefania Brozzetti
    • 2
  • Ugo Boggi
    • 1
    Email author
  1. 1.Division of General and Transplant SurgeryUniversity of PisaPisaItaly
  2. 2.Pietro Valdoni Department of SurgeryUniversity of Rome La SapienzaRomeItaly

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